DIAGNOSIS AND MANAGEMENT CENTRAL RETINA L ARTERY OCCLUSION

diagnosis and management central retina artery occlusion

1. DIAGNOSIS & MANAGEMENT
CENTRAL
RETINAL ARTERY
OCCLUSION
(CRAO)
DEPARTMENT OF OPTHALMOLOGY
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY

2. Itisanocularemergencycharacterizebypathologicalconditionofreduced
bloodflowtotheinnerlayeroftheretinathroughthecentralretinalarterydue
totheobstructionofbloodflow.
CRAO
Patel, PS., SraddaSRmSarrafD. 2022. Retinal Artery and Capillary Occlusions in. Ryan’s Retina Volume 2 : 7
th
Edition. USA-Elsevier
American Academy of Ophtalmology.2023. Retinal and Ophthalmic Artery Occlusions Preferred Practice Pattern. USA-Elsevier

3. ETIOPATHOGENESIS
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
Embolism
-Most common
-Atherosclerosis
-3 types :
1. Cholesterol
(Hollenhorst)
2. Platelet-fibrin
3. Calcium
Thrombosis
Acquired or hereditary
Virchow’s triad :
1. Vessel wall
abnormalities
2. Stasis blood flow
3. Changes in blood
components
Vasculitic
Clasicallyoccurs in GCA
(vasculitic+ thrombosis)
and other systemic
vasculitis (RA, SLE,
Behcet’sdisease)

4. ETIOPATHOGENESIS
Patel, PS., SraddaS, Rm SarrafD. 2022. Retinal Artery and Capillary Occlusions in. Ryan’s Retina Volume 2 : 7
th
Edition. USA-Elsevier

5. CLASSIFICATION
Non-arteritic permanent
CRAO
Non-arteritictransient
CRAO
Non-arteritic CRAO with
cilioretinal sparing
Arteritic CRAO
CRAO
Hayreh and Zimmerman Classification
Sohan Singh Hayreh, M. Bridget Zimmerman. Central Retinal Artery Occlusion: Visual Outcome,AmericanJournal of Ophthalmology, Volume 140, Issue 3. 2005.

6. CLASSIFICATION
Sohan Singh Hayreh, M. Bridget Zimmerman. Central Retinal Artery Occlusion: Visual Outcome,AmericanJournal of Ophthalmology, Volume 140, Issue 3. 2005.
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide
Non-arteriticpermanent
CRAO
•2/3 of all cases
•Majority ec.Platelet-
fibrin thrombi & emboli
as a result of
atherosclerotic desease
Non-arteritictransient
CRAO
•Transient monocular
blindness
•Restoration of blood
flow →symptom
resolution
•Best visual prognosis
Non-arteriticCRAO
with cilioretinal sparing
•A. Cilioretinal present in
45.9% patients
•Preserved perfusion
ArteriticCRAO
•Always due to GCA
•Occur in approximately
4.5% of CRAO cases

7. DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide
CRAO
History of
visual loss
Evaluation of
risk factors
General
physical
examination
Ocular
examination
Ancillary
investigation

8. 1.History
-Painless,sudden,unilaterallossofvision
-Amaurosisfugax
-Headacheandscalptenderness→GCA
2.Evaluationriskfactors
-Familyhistorycerebrovascular/cardiovasculardisease,DM,hyperlipidemia.
-Noatheroscleroticriskfactors:vasculitis,sicklecell,hypercoagulable
states,medication?
CLINICAL PRESENTATION
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide

9. 3.Generalphysicalexaminationfindings
-Assesmentofvascularrisk(mostly),autoimmunedisease(vasculitisrelated)
-Scalptenderness+nodulartemporalarteries(GCA)
4.Ocularfindings
--lookatthecontralateraleye -opticdiscpallor(39%)
--RAPD(+) -cattletrucking/boxcarring(19%)
--cherry-redspot(90%) -retinalarterialattenuation(32%)
--retinalopacity(58%)
CLINICAL PRESENTATION
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide

10. -FundusExamination
CLINICAL FEATURES
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
(A)LeftfundusphotoofacaseofCRAOshowinggeneralizedwhiteningofretina,attenuatedarterioleswithpresenceof
cheryredspot(blackarrow)inthecentreofmacula;and
(B)Showingapatchofnormallyperfusedretinaintheareaofbloodsupplyofcilioretinalartery(papulomacularbundle)
surroundedbygeneralizedwhiteningofretinasuggestiveofsparingofcilioretinalarteryinacaseofCRAO
Cattletrucking/boxcarring

11. -FundusExamination
CLINICAL FEATURES
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
Patel, PS., SraddaSRmSarrafD. 2022. Retinal Artery and Capillary Occlusions in. Ryan’s Retina Volume 2 : 7
th
Edition. USA-Elsevier
Rightfundusphotoshowingsmall,yellowish,glistening
cholesterolembolus(Hollenshostplaque)atthedisc)
Cholesteroplembolusatanarterialbifurcationalongthe
superotemporalarcade
‘ground-glass’appearance

12. -FundusExamination
CLINICAL FEATURES
Fundusphotographsshowingaretinalembolus.(a)Cholesterolembolus,(b)fibrinplateletembolus,and(c)calcificembolus.
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide

13. -FundusExamination
CLINICAL FEATURES
(A)Acutecentralretinalarteryocclusionwithcilioretinalarterysparing.(A)Retinalopacificationisclearlydemarcatedaround
thepre-servedmaculaperfusedbythepatentcilioretinalartery.Theperfusedareaincludesthefovea;therefore,the
patient’spresentingvisualacuitywasgood.
(B)At25seconds,fluoresceinangiographyshowsprefusionofthecilioretinalarteryanddyeinveinsdrainingareassupplied
bythisvessel.(CourtesyDr.JiongYan,EmoryEyeCenter,Atlanta.)
Patel, PS., SraddaSRmSarrafD. 2022. Retinal Artery and Capillary Occlusions in. Ryan’s Retina Volume 2 : 7
th
Edition. USA-Elsevier

14. -FundusExamination
CLINICAL FEATURES
Chroniccentralretinalarteryocclusion.
Opticnervepallorbecauseofatrophyand
severearterialattenuationisnotedinthis
patientwitharemotecentralarteryocclusion.
Patel, PS., SraddaSRmSarrafD. 2022. Retinal Artery and Capillary Occlusions in. Ryan’s Retina Volume 2 : 7
th
Edition. USA-Elsevier

15. -SD-OCT
ANCILLARY STUDIES
Opticalcoherencetomographyofapatientwithcentralretinalarteryocclusion(CRAO)showingirregularfovealcontourwith
increasedreflectancefrominnerretinallayersduetoretinaledema.
RavaniR, Agrawal S, et.al. Retinal Arterial Occlusion in Reitina: Medical and Surgical Management : Ch.22 p.256. Jaypee Medical Publishers : 2018.

16. -SD-OCT
ANCILLARY STUDIES
Spectraldomainopticalcoherencetomography(SD-OCT)ofacutecentralretinalarteryocclusion(CRAO).Anirregularfoveal
contourisseenwithahighlyreflective,thickenedinnerretina.Theouterretinaisrelativelyhyporeflectivebecauseofshadowing
fromthethickenedinnerretina.Theexternallimitingmembrane,ellipsoidzone,andretinalpigmentepitheliumareintactbutwith
decreasedreflectivitybecauseoftheshadowingeffectfromthehyperreflectiveinnerretinallayers
Courtesy BakhoumMF, Freund KB, Dolz-Marco R, LesongBCS, BaumalCR, DukerJS, et al. Paracentral acute middle maculopathy and the ischemic cascade associated with retinal vascular occlusion. Am J Ophthalmol
2018;195:143–53

17. -FFA
ANCILLARY STUDIES
FFAoftherighteyeshowingadelayin
thearterialfillinginCRAOat32s,1m
40s,3min44s,and5min35s.
Alsoreducedarterialcalibreand‘cattle
trucking’appearance
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide

18. MANAGEMENT
CRAO
Work up for associated Systemic
Condition to Establish Etiology
Management of
sequelae
Management of acute
episode
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.

19. 1. Work up for associated Systemic Condition to Establish Etiology
-URGENT REFERRAL to an emergency department for stroke work up
-National Stroke Association + AHA : retinal cell death = central nervous
system infarction/stroke
-1
st
line screening test : USG Carotid / Color Doppler
-All test SHOULD NOT DELAY TREATMENT.
MANAGEMENT
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide

20. 2. Acute Episode
-Irreversible damage to inner retinal tissue 90-100 minutes following CRAO
-People are rarely seen acutely
-No consensus for treatment or guideline-based therapy
-If GCA is established : high dose steroid therapy
-Principle of treatment :
1.Dislodging emboli or lysing the thrombus
2.Maintaining retinal oxygenation
3.Vasodilatation of the ocular blood supply
4.Reducing IOP
5.Increasing retinal blood flow
MANAGEMENT
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide
RavaniR, Agrawal S, et.al. Retinal Arterial Occlusion in Reitina: Medical and Surgical Management : Ch.22 p.256. Jaypee Medical Publishers : 2018.

21. MANAGEMENT
Courtesy BakhoumMF, Freund KB, Dolz-Marco R, LesongBCS, BaumalCR, DukerJS, et al. Paracentral acute middle maculopathy and the ischemic cascade associated with retinal vascular occlusion. Am J Ophthalmol2018;195:143–53
DD Varma, S Cugati, AW Lee, CS Chen. 2013. A Review of Central Retinal Artery Occlusion : Clinical Presentation and Management. Eye 27, 688-697. Macmillan Publishers : Adelaide
‘Standard’
Non-invasive measures
•(i) ISDN / inhalation of carbogen/breathing into paper bag/ hyperbaric oxygen
•(ii) Ocular digital massage
•(iii) Acetazolamide/Mannitol IV + AC paracentesis
•(iv) Multimodal stepwise approaches
Thrombolytic
agents
AHA recommends tissue plasminogen activator in the following :
-Intravenous tPA for patients without systemic contraindication and who are evaluated within 4.5 hours of
onset of visual symptoms; or
-Intra-arterial tPA, through superselectivecatheterization of the ipsilateral ophthalmic artery, for patients who
are not candidates for intravenous therapy and who are evaluated within 6 hours of onset of visual symptoms.

22. MANAGEMENT
Schumacher, M. et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 117, 1367–1375.e1 (2010).
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.

23. 3. Sequelae
-Neovascular glaucoma is reported in 2-16% cases
-Treatment :
1.Laser PRP
2.Topical antiglaucoma
3.Glaucoma valve implants
4.Cyclodestructiveprocedures (TSCPC)
MANAGEMENT
SunandanSood. 2018. Retinal Artery and Ophthalmic Artery Occlusions in Disorders of Retina and Vitreous. CBS Publishers –India.
https://eyewiki.aao.org/Cyclodestructive_Procedures_in_Treatment_of_Glaucoma#cite_note-:5-5

24. OphthalmicArteryOcclusion BranchRetinalArteryOcclusion
DIFFERENTIAL DIAGNOSIS
https://imagebank.asrs.org/file/65281/ophthalmic-artery-occlusion-in-a-39-year-old-with-rheumatoid-arthritis
https://webeye.ophth.uiowhttps//webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Hollenhorst-plaque-BRAO-cherry-red-spot.htm#gsc.tab=0a.edu/eyeforum/atlas/pages/Hollenhorst-
plaque-BRAO-cherry-red-spot.htm#gsc.tab=0

25. ParacentralAcuteMiddleMaculopathy CommotioRetinae
DIFFERENTIAL DIAGNOSIS
Makino S. Paracentral acute middle maculopathy. Digit J Ophthalmol. 2022;28(3). Accessed June 7, 2024. https://djo.harvard.edu/index.php/djo/article/view/144
Tripathy K, Patel BC. Cherry Red Spot. [Updated 2023 Aug 25]. In: StatPearls[Internet]. Treasure Island (FL): StatPearlsPublishing; 2024 Jan-. [Figure, Commotio Retinae With Foveal
Involvement...] Available from: https://www.ncbi.nlm.nih.gov/books/NBK539841/figure/article-19380.image.f3/

26. TaySachsDisease CentralRetinalVeinOcclusion
DIFFERENTIAL DIAGNOSIS
https://www.atlasophthalmology.net/photo.jsf;jsessionid=3762173DC44439D4286A267C760B2891?node=10079&locale=pt
Torres Soriano, Mitzy& García-Aguirre, Gerardo & Gordon, Maximiliano & Kon-Graversen, Veronica. (2018). Diagnostic Atlas of Retinal Diseases Volume 1. 10.2174/97816810835751160101.

27. -<10%patientsregainfunctionalvision
-VisualimprovementwasmostnotableintransientnonarteriticCRAO
-Increasedriskofrecurrentvascularevents
-Mayresultinhighermortalityratescomparedtogeneralpopulation
PROGNOSIS
SchragM, YounT, Schindler J, Kirshner H, Greer D. Intravenous Fibrinolytic Therapy in Central Retinal Artery Occlusion: A Patient-Level Meta-analysis. JAMA Neurol. 2015 Oct;72(10):1148-54. [PubMed]
Hwang DD, Lee KE, Kim Y, Kim MS, Rim TH, Kim M, Kim H, Kyoung DS, Park JI. Incidence of Retinal Artery Occlusion and Related Mortality in Korea, 2005 to 2018. JAMA NetwOpen. 2023 Mar 01;6(3):e233068.

28. Innerretinalthinning
Anopticalcoherencetomography(OCT)image
oftheno-refloweyeshowslossoflayer-by-layer
structureintheinnerretinaandremarkable
macularthickening.Incontrast,therefloweye
showsarelativelypreservedlayeredretinal
structureatbaseline(top)and1(middle)and6
months(bottom)later.Furthermore,theno-reflow
eyeshowsmoreremarkableretinalthinningthan
therefloweyeandlossofanorganizedlayered
retinalstructureinthemacula.
COMPLICATIONS
Joon Ahn, Seong; Park, Kyu Hyung; Ryoo, Na-Kyung; Hong, Jeong-Ho; Jung, Cheolkyu; Yoon, Chang-Hwan; et al. (2015). Structural changes in the retina over time in the reflow (left) and no-reflow (right) eyes for central
retinal artery occlusion (CRAO).. PLOS ONE. Figure. https://doi.org/10.1371/journal.pone.0142852.g004

29. DiscAtrophy CentralRetinalVeinOcclusion
COMPLICATIONS
https://imagebank.asrs.org/file/29559/old-central-retinal-artery-occlusion
Jung YH, Ahn SJ, Hong JH, et al. Incidence and Clinical Features of Neovascularization of the Iris following Acute Central Retinal Artery Occlusion. Korean J Ophthalmol. 2016;30(5):352-359.
doi:10.3341/kjo.2016.30.5.352

30. THANK YOU
OPTHALMOLOGY DEPARTMENT HASANUDDIN UNIVERSITY